Wednesday, July 27, 2011

Four Reasons Why “Loss Aversion” Could Be An Effective Weight Loss Approach in Work Site Wellness Programs Targeting Obesity

Who's Going To Pay For This?

Given the economic costs associated with obesity, should we pay persons to lose weight in the hope that this will result in a long-term return on investment? While that may be a good idea, the Disease Management Care Blog doubts commercial or government insurers will ever pay people to diet.

Yet, that doesn’t mean that we can't leverage “behavioral economics” in wellness programs. That brings the DMCB to this interesting gem of a study by Leslie John and colleagues that was reported in the Journal of General Internal Medicine titled “Financial Incentives for Extended Weight Loss: A Randomized Controlled Trial.” Even though the results were ultimately disappointing, the approach that was used may have considerable merit.

The DMCB explains.

"Loss aversion" is the well-known tendency of persons to attach greater value to economic losses than gains. The authors capitalized on this by testing the impact of a “deposit contract” on 66 obese Philadelphia VA patients who put their own money at risk. This was a 32 week (24 weeks of weight loss followed by an 8 week maintenance phase) trial that randomly allocated participants to one of three treatment arms:

1) a contract in which participants contributed up to $3 per day for a month to a fund that was matched 1:1 by the researchers. The participants had to report their weight on a daily basis by telephone. They were given credit for the day if their weight was equal to or less than a daily weight loss goal that was configured to ultimately result in a loss of 24 pounds in 24 weeks. After each call, participants were given feedback via telephone text message. There was a weigh-in at the end of each month. If the weight target for the month was not met, all the money was forfeited. The 24 weeks was followed by an 8 week period of weight maintenance that was described to the participants as “maintenance of weight loss period”

2) the same contract but there was no description of the 8 week period as “maintenance” and

3) a concurrent control group.

22 persons were assigned to each of the three treatment arms. Between 18 to 19 of each of the three groups were male. The the BMI ranged between 34 and 35 with an average weight of around 230 lbs.
There was no difference in the weight loss at 32 weeks for the two treatment arms of the study, with a mean weight loss of 9.7 and 7.8 lbs, respectively. During the same period, however, the control patients only lost 1.2 lbs. Three months into the study, 50% of the intervention patients who were not meeting target chose to continue contributions even as they were falling behind. Once the program was over, persons returned 36 weeks later for a final weigh-in and most regained their weight. The forfeited money was evenly distributed to participants that had lost 20 or more lbs. during the study.

As the DMCB said, this was a disappointing study. Yet, the DMCB wonders if this approach couldn’t be successfully adapted to a typical employer-sponsored obesity wellness program.

Here’s four reasons why:

1) One of many building blocks: there may be something to the use of behavioral economics in modern psychological approaches to behavior change. While the purpose of this classic randomized clinical trial was to assess the impact of a single discreet financial incentive, wellness program architects understand that interventions such as this can be combined with others, resulting in a synergistic approach that is greater than the sum of its parts. Therefore, while it doesn’t seem to work as a stand-alone program at the Philadelphia VA, it could work as a program component at a worksite wellness initiative.

2) Show me the money: employers are constantly looking for approaches in which employees have “skin in the game.” The idea that persons would put up their own money on behalf of their own wellness is a compelling concept that should gain the approval of the flintiest hard-nosed CEO. In fact, it appears there is a good chance this approach could actually net some money. The DMCB says give it to charity.

3) You, yes you, can plan, execute, evaluate and adjust this: the infrastructure necessary to support an intervention such as this is well within reach of employers, who could use standard payroll deductions, employer matching, networked workplace weight scales and corporate intranet supported feedback. They also have the data systems that could be used to support an observational data base or a quasi-experimental study to assess whether the program is meaningfully successful.

4) Part of the menu (no pun intended): Last but not least, the DMCB doesn’t think there is any single approach to weight loss. Some persons may have a psychological profile that makes them better suited to "loss aversion" as a weight loss strategy. Perhaps this could be measured using a health risk assessment. By offering this side by side on a targeted basis along with other weight loss program options, the DMCB thinks an employer could achieve even greater success than with any single “one size fits all” strategy.

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Here's what one reader had to say about the Population Health Blog's ability to to go beyond simple headlines and mainstream newsfeeds:

"This past week, I was surprised to read some of the generic headlines summarizing the VA readmission study. You know, through medical newsfeeds, they almost implied that length of stay didn't have anything to do w/readmissions. When I read the Annals article today, there was certainly a lot more to the study than that. Was happy to see your nice summary, which I agree w/100%. Just wanted to drop you a line to say that Ilooked at your blog w/hopes of finding some commentary on the study---and there it was!"

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About Jaan Sidorov MD, MHSA, FACP

While his web persona has been described as a "blogvocateur," Dr. Sidorov has wide range of knowledge about the medical home, condition management, population-based health care and managed care that is only exceeded by his modesty. He has been quoted by the Wall Street Journal, Consumer Reports and NPR’s All Things Considered.
He has over 20 years experience in primary care, disease management and population based care coordination. He is a primary care general internist and former Medical Director at Geisinger Health Plan.
He is primary care by training, managed care by experience and population-based care strategies by disposition.
The contents of this blog reflect only the opinions of Sidorov and should not be interpreted to have anything to do with any current or past employers, clients, customers, friends, acquaintances or enemies, personal, professional, foreign or domestic. This is also not intended to function as medical advice. If you really need that, work with a personal physician or call 911 for crying out loud.
Jaan can be reached at jaansATaolDOTcom.